Oroville Hospital Implements VistA, part 2

by guest author Matthew N. Fine, MD

This is the second in Dr Fine’s two-part series describing Oroville Hospital‘s implementation of VistAthe open-source EHR developed by the Veterans’ Administration. In his first post, he discussed their strategic approach and initial experiences with electronic documentation. Here, he picks up with Oroville Hospital’s CPOE go-live. – RC

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

After a whole year of hybrid charts the staff was chomping at the bit to go live and the anticipation outweighed the fear. Turning on CPOE was almost a welcomed event – watch out what you wish for. I think the (unintentional) strategy of having hybrid charts may be a good way to make full conversion to EHR more palatable.  CPOE was turned on October 15, and by the end of the first week nearly 70% of the orders were electronic and it’s now about 80%. There are holdouts among some of the physicians, notably surgeons and OB/Gynes.  Does anyone else have this problem? The hospitalists have a co-management arrangement with the surgeons, so most of their patients’ orders are electronic. This situation has actually give the EHR staff a little breather, enabling them to clean up many of the minor problems, including building a number of new orders sets – everything on VistA is easier with an order set.  We expect that CPOE will be mandatory within two months.  The pharmacy has created weight-based medication orders for pediatrics.  We don’t have a neonatal ICU, but it’s felt that the CP Flowsheet module could be adapted for this function. We are still working on a better medication reconciliation system.

Now, three weeks after the “go live” it’s still somewhat hectic and there are numerous minor and a number of major refinements required.  Dr. Singh our CMIO wondered when he would be able to go back to doing more clinical work – never!  Most of the problems have been delay in care, but a lot of the orders are carried out more quickly since they are sent directly to the appropriate department. There was a wrong medication entered by a pharmacist due to our still partly paper medication reconciliation system. Despite the challenges, some of our nurses and physicians, who also work in other area hospitals with proprietary systems, already prefer VistA.

Stage I meaningful use was achieved in 2011 and 2012 for the hospital and some of the clinics.  We are working on Stage II.

The EHR staff has participated extensively in the WorldVistA and, recently, OSEHRA, VistA’s non-governmental arm.   Oroville Hospital’s efforts are well known to the VistA community.  More than 100 patches to FOIA version of VistA have been created and some are being used by the VA in general.  The hospital is continuing to build additional enhancements and modules with the open source community.  Oroville Hospital made the necessary modifications and financed some other products through WorldVistA to get VistA certified by CCHIT. These upgrades include the ePrescribe system, which allows prescriptions to be sent to retail pharmacies through a clearing house, and has just been released to open source by WorldVistA.

Web based products were developed with collaborators in London. Enterprise Web Developer (EWD) was used as a framework to rapidly build rich web applications over a MUMPS database.  It allows us to deliver content to any device regardless of operating system, including iOS, Mac, Linux, Android and Windows based clients, eliminating device constraints. A number of our providers use an iPad to access information, but prefer mouse based computers for entering orders and writing notes. Also using EWD, Oroville has developed a real-time dashboard to monitor orders and other patient activity.  A patient portal for access to records from home will be rolled out next month.

For the last two years a number of clinics have been sharing health information. Last week Narinder and Denise participated in a regional HIE meeting in Sacramento that will allow for the trading of records with our SacValley MedShare HIE, of which Oroville Hospital is one of four core members.

Being from the clinical (the light) side of the project, I know I’ve given short shrift to the technological accomplishment of the team.  The usual progression of my requests for a new function is “the system can’t do that” to “it’s hard and will take a long time” to “I’ve got something to show you.” I also want to acknowledge the hard work done by many members of our staff.  Our HIT department is relatively small, so each department played a large part in developing their specific components.  Pharmacy, nursing and nutrition deserve special mention.

The total cost of the system, from soup to nuts, has been about $14 million.  Compared to proprietary systems, this amount contains a significantly higher proportion of hardware expenditures, including servers to support VMware.  This decision allowed the hospital to provide enough devices for all users, including dummy devices, and to let them use their preferred device.  Even though the system is open source, there will probably be some return on investment such as fees for use of the clearing house function for ePrescribe, consultation charges, and licensing for the order sets.  A detailed breakdown of the costs is covered in an upcoming article in the Open Health News.  If another non-VA hospital choses to use the use the system, it is felt their costs would be considerably less since they would not have the development expenses.

Bob Wentz said that he has been asked a number of times how a small hospital ended up developing an e-prescription system; he tells them – and I think his answer applies to the system as a whole – “Because we needed to.”

Oroville Hospital Implements VistA

by guest author Matthew N. Fine, MD

Several years ago I had the pleasure of meeting Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety at Oroville Hospital, at UCSF’s annual CME course Management of the Hospitalized Patient.  When Dr Fine attended the course again this year, he told me Oroville Hospital had recently gone live with CPOE on VistA, the EHR developed by the Veterans’ Administration. I’ve invited Dr Fine to post a two-part series here on Oroville Hospital’s experience. In this first part, he discusses their strategic approach and their initial experiences with electronic documentation, and in the second, their CPOE go-live. — RC

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

On October 16, 2012, Oroville Hospital turned on the CPOE component of its EHR, becoming the first individual US hospital to successfully adapt the Veterans’ Administration’s highly regarded electronic medical records system. How did a small, 153 bed semirural California hospital serving a mostly Medicare and MediCal population arrive at this place?

Almost exactly six years before, in October 2006, I attended the EMR and CPOE workshop with Drs. Russ Cucina and Michael Blum at the UCSF Hospital Medicine conference chaired by Dr. Bob Wachter.  The last thing Dr Cucina mentioned was the VistA system, which he said had barriers to its use at a non-VA hospital. At Oroville Hospital we had been discussing what do about EHR. We found that the proprietary systems were expensive, less than functionally ideal, and we didn’t want the tail wagging the dog. At one of our meetings in early 2007 I remembered I’d heard about the VA system and that “it’s free.” That night our CEO, Bob Wentz, downloaded the program.

We explored working with private companies that were marketing VistA with some embellishments and impressive consulting fees. They also retained proprietary rights to the system, restricting or charging for modification and thereby closing the open source. The hospital leadership decided to see if we could do it ourselves. The CIO retired and moved to Mexico.

We visited several VA hospitals to see the system in operation.  Whenever we spoke with residents, who also work at their university hospital, we found they preferred the VA system.  A team was assembled including Dr. Narinder Singh, a techy internist who had helped implement an outpatient system, Denise LeFevre, the new CIO who had started working at Oroville Hospital about 25 years ago while still in high school, the CEO Robert (we can do this) Wentz, CEO and Zach (the ex-pizza guy) Gonzales, now Director of VistA Development.

Initially, they chose Linux over Windows and a non-proprietary data base GT.M was used instead of Cache to complete the open-source stack. The EHR team took classes from consultants to learn the functionality of the system. They learned what they could do on their own and for what they needed VistA clinical application coordinators from various disciplines. They traded ideas with the country of Jordan, which is also implementing VistA. Some of the consultants worked in both places.

In April of 2009 I started using the system in my office practice.  I insisted on a small mobile cart with a small device – I got a notebook, so I could look at the patient no matter where they were in the room.  At first we had “flat templates” which were soon replaced with ones that were more flexible and interactive. The mental work of learning a new system while taking care of patients was a real challenge, which I’m sure is the case for many physicians “of a certain age.” After about six months, I felt comfortable with the system and after about a year and half you couldn’t take it away from me.  Having known that the system would be trialed in my office, I did a time utilization study before and after EHR.  Before EHR, a routine follow-up encounter took about 10 minutes of which total clinical time (including multitasking) was 8:57 and undivided clinical time was 6:22.  Six weeks into EHR a visit took about 16 minutes and total clinical time was almost the same at 8:12, but undivided clinical time had fallen to 3:02. Follow-up visits are now taking about 12 minutes, but I feel the clinical only time has gone up considerably.  My long time patients often say something like “Wow, your typing has improved.”  While the EHR team was working on the inpatient side, over the next two years we added about twenty other clinics including pediatrics.

Slowly our homegrown and consulting geeks, many of whom had vast VistA experience began designing, building and arranging for the necessary components of the system. An interface was constructed for our Sunquest lab system which serves the hospital and many affiliated and independent clinics.  A McKesson PACS system for imaging was installed and integrated with VistA using HL7.  An electronic prescription system was developed from scratch.

Billing was a major issue. The hospital had a well-functioning financial management system and we did not want to interrupt the cash flow, so it was decided it should not be disturbed. Instead, an interface with the billing system was created that sends the needed pieces for billing to a proprietary system.

Even before the EHR was contemplated, the medical staff had been developing paper order sets. By 2011 there were almost 100. They had been designed using a systematic format, so they could be converted with few changes to CPOE. Since the providers were very familiar with them and had participated in their creation, acceptance has not been a significant problem.

Gradually the medical information was linked to VistA so the system would be “VistA-centric”. By the summer of this year the process was almost complete including lab, imaging, and dictated reports. Most recently ECGs, echocardiograms, and ABGs were added. All the nursing notes and most of the progress notes were being documented on the computer. The ICU flow sheet was created using the VA’s CP Flowsheet module and implemented at the same time as CPOE.  It’s complex and slow, but is being improved almost daily and will be used as the basis for anesthesia, obstetrical, and infusion center flow sheets.